{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T07:42:57Z","timestamp":1792482177605,"version":"4.5.0"},"reference-count":29,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:00:00Z","timestamp":1788307200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:00:00Z","timestamp":1788307200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100001080","name":"Patrick and Catherine Weldon Donaghue Medical Research Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100001080","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Services Research"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To examine whether out\u2010of\u2010pocket costs during pregnancy and delivery affect use of postpartum care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Setting and Design<\/jats:title>\n                    <jats:p>Because health insurance deductibles and limits reset annually, the timing of childbirth within that year quasi\u2010randomly assigns people to different levels of cost\u2010sharing during pregnancy+delivery versus postpartum. We use a novel instrumental variable approach that leverages this variation to analyze whether higher maternity spending due to delivering early in the plan year affects postpartum care utilization. The exposure is maternity out\u2010of\u2010pocket spending, and the instrument is whether the delivery was in the first three versus last 3\u2009months of the enrollee's health plan year; the primary outcome is use of any outpatient care postpartum. We analyze maternity episodes among Blue Cross Blue Shield of Massachusetts enrollees who gave birth, 2019\u20132023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources and Analytic Sample<\/jats:title>\n                    <jats:p>\n                      Commercial health insurance enrollment and claims data for individuals with continuous enrollment during pregnancy, delivery, and 3\u2010months postpartum (\n                      <jats:italic>N<\/jats:italic>\n                      \u2009=\u200951,337).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal Findings<\/jats:title>\n                    <jats:p>Out\u2010of\u2010pocket costs for those delivering at the start versus the end of their health plan year were, on average, 21% higher for pregnancy+delivery care and 58% lower for postpartum care. A $100 increase in pregnancy+delivery out\u2010of\u2010pocket spending led to a 0.53 percentage point (95% CI [0.28, 0.79]) increase in use of any outpatient postpartum care (sample mean: 82.5%). Higher pregnancy+delivery out\u2010of\u2010pocket costs also led to significant increases in the number of outpatient contact days, visits for preventive\/well care, visits for mental health, and other visits.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Higher pregnancy+delivery out\u2010of\u2010pocket costs due to delivering early in the plan year corresponded to lower postpartum out\u2010of\u2010pocket costs and led to modest increases in postpartum care. This suggests that lower postpartum cost\u2010sharing may increase postpartum care use. Policies that lower those costs may be effective in increasing use of postpartum care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1475-6773.70161","type":"journal-article","created":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T07:54:41Z","timestamp":1788335681000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Delivery Timing, Out\u2010Of\u2010Pocket Maternity Costs, and Postpartum Care Utilization: An Instrumental Variable Analysis Among Commercially Insured Women"],"prefix":"10.1111","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7656-0811","authenticated-orcid":false,"given":"Rebecca A.","family":"Gourevitch","sequence":"first","affiliation":[{"name":"Department of Health Policy and Management University of Maryland  College Park Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica L.","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Global Health and Population Harvard T.H. Chan School of Public Health  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tara","family":"Shakley","sequence":"additional","affiliation":[{"name":"Blue Cross Blue Shield of Massachusetts  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sung Min","family":"Park","sequence":"additional","affiliation":[{"name":"Blue Cross Blue Shield of Massachusetts  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5055-8473","authenticated-orcid":false,"given":"Mary Beth","family":"Landrum","sequence":"additional","affiliation":[{"name":"Department of Health Care Policy Harvard Medical School  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3410-0184","authenticated-orcid":false,"given":"Meredith B.","family":"Rosenthal","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management Harvard T.H. Chan School of Public Health  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark W.","family":"Friedberg","sequence":"additional","affiliation":[{"name":"Blue Cross Blue Shield of Massachusetts  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4230-1947","authenticated-orcid":false,"given":"Anna D.","family":"Sinaiko","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management Harvard T.H. Chan School of Public Health  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,2]]},"reference":[{"key":"e_1_2_10_2_1","volume-title":"From Prenatal Through Postpartum Care, It Cost More Than $24,000 to Have a Baby on Average","author":"Valencia Z.","year":"2023"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/og9.0000000000000136"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.32103"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0000000000004704"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11606\u2010023\u201008214\u20103"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2024.5565"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/1468\u20100009.12721"},{"key":"e_1_2_10_9_1","volume-title":"Senators Introduce Bipartisan Bill to Ease the Financial Burden of Pregnancy, Childbirth","author":"Cindy Hyde\u2010Smith","year":"2025"},{"key":"e_1_2_10_10_1","unstructured":"C.Hammer A.Blake R.Heckel M.Caverly A.LaRocco andB.Darby \u201cAnalysis of Reducing or Eliminating Cost Sharing for Maternity Services in Washington State \u201d(2024) https:\/\/app.leg.wa.gov\/ReportsToTheLegislature\/home\/GetPDF?fileName=Milliman%20\u2010%20WA%20Maternity%20Cost%20Sharing%20Report%2020240626\u2010FINAL_ca490aaf\u20100018\u201042b6\u2010823f\u20107ee40a221570.pdf."},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpubeco.2024.105152"},{"key":"e_1_2_10_12_1","volume-title":"Free for All?: Lessons From the RAND Health Insurance Experiment","author":"Newhouse J. 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